FM-Gorman 11/20/01 1:01 PM Page ii

LINDA M. GORMAN, RN, MN, CS, OCN, CHPN

Palliative Care/Hospice Clinical Nurse Specialist
Cedars-Sinai Medical Center
Los Angeles, California

Assistant Professor
University of California, Los Angeles
Los Angeles, California

Certified Clinical Nurse Specialist

Adult Psychiatric/Mental Health Nursing

MARCIA L. RAINES, PhD, RN, MN, CS

Chair and Professor
California State University, San Bernardino
San Bernardino, California

Certified Clinical Nurse Specialist

Adult Psychiatric/Mental Health Nursing

DONNA F. SULTAN, RN, MS

Mental Health Counselor, RN
West Valley Mental Health Center
Los Angeles County Department of Mental Health
Los Angeles, California
FM-Gorman 11/20/01 1:01 PM Page iii

Psychosocial
Nursing
for General Patient Care

SECOND EDITION

F. A. DAVIS COMPANY • Philadelphia

FM-Gorman 11/20/01 1:01 PM Page iv

F.A. Davis Company

1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2002 by F.A. Davis Company

Copyright © 1996 by F.A. Davis Company. All rights reserved. This book is protected by copy-
right. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without writ-
ten permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Joanne DaCunha

Developmental Editor: Diane Blodgett
Cover Designer: Louis Forgione

As new scientific information becomes available through basic and clinical research, recom-
mended treatments and drug therapies undergo changes. The author(s) and publisher have done
everything possible to make this book accurate, up to date, and in accord with accepted stan-
dards at the time of publication. The authors, editors, and publisher are not responsible for er-
rors or omissions or for consequences from application of the book, and make no warranty, ex-
pressed or implied, in regard to the contents of the book. Any practice described in this book
should be applied by the reader in accordance with professional standards of care used in regard
to the unique circumstances that may apply in each situation. The reader is advised always to
check product information (package inserts) for changes and new information regarding dose
and contraindications before administering any drug. Caution is especially urged when using
new or infrequently ordered drugs.

Library of Congress Cataloging in Publication Data

Gorman, Linda M.
Psychosocial nursing for general patient care / Linda M. Gorman, Marcia L. Raines, Donna F.
Sultan.—2nd ed.
p. cm.
Previous ed. published with title: Davis’s manual of psychosocial nursing for general patient
care.
Includes bibliographical references and index.
ISBN 0-8036-0802-0 (pbk. : alk. paper)
1. Psychiatric nursing—Handbooks, manuals, etc. 2. Nursing—Social aspects—Handbooks,
manuals, etc. I. Luna-Raines, Marcia. II. Sultan, Donna. III. Gorman, Linda M. Davis’s manual
of psychosocial nursing for general patient care.

RC440 .G659 2002

610.73
68—dc21
2001047637

Authorization to photocopy items for internal or personal use, or the internal or personal use of
specific clients, is granted by F.A. Davis Company for users registered with the Copyright Clear-
ance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid
directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have
been granted a photocopy license by CCC, a separate system of payment has been arranged. The
fee code for users of the Transactional Reporting Service is: 8036-0802/02 0  $.10.
FM-Gorman 11/20/01 1:01 PM Page v

PREFACE

Having worked in a variety of specialty areas over the years as staff nurses,
clinical nurse specialists, educators, and managers, we realize that nurses as-
pire to become highly proficient in their area of practice but that psychosocial
skills are often more difficult to perfect. Very often nurses feel inadequately
prepared to deal with complex behaviors and psychiatric problems. Even
nurses who practice in the psychiatric setting find themselves dealing with
unique situations that challenge their level of expertise. And yet, a large per-
centage of nurses’ time is spent dealing with these issues.

Psychosocial Nursing for General Patient Care bridges the gap between the in-
formation contained in large, comprehensive psychiatric nursing texts and
the information needed to function effectively in a variety of healthcare set-
tings. The clinician can refer to this book to find the information to effectively
handle specific patient problems. The nursing student can use this book as a
review of basic psychosocial information that will be useful throughout nurs-
ing school curriculum.

The concise, quick reference format allows the nurse to easily find informa-
tion on a specific psychosocial problem commonly seen in practice. In addi-
tion to common psychosocial problems, psychiatric disorders are explained
and discussed. Information on etiology, assessment, age specific implica-
tions, nursing diagnosis and interventions, patient/family education, phar-
macologic approaches, and community-based care is provided.

Today’s fast-paced healthcare environment demands quick assessment and

treatment plans that are realistic, cost-effective, and outcome driven. The infor-
mation contained in this book is readily applicable to all patient care settings.

Each psychosocial problem includes a section on common nurses’ reactions to

the patient behaviors that may result from the problem. Nurses often think they
should have only acceptable and “proper” emotional reactions to their pa-
tients. The nurses may deny certain feelings and have unrealistic expectations
of themselves. These factors impact how the nurse then responds to the pa-
tient’s problems. The more aware the nurse becomes of how one reacts to a pa-
tient’s behaviors the easier it will be to accept one’s own feelings and under-
stand how these feelings affect the patient and influence interventions.

v
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vi PREFACE

This second edition provided us with the opportunity to add chapters on two
important areas: culture and end-of-life care. In addition, chapters now in-
clude information on alternative and complementary approaches where ap-
propriate. Nurses need to be familiar with the herbal products and nonphar-
macologic approaches that patients use and how these choices can impact
other treatment modalities. The increased emphasis on care outside of the
acute hospital has been expanded in this edition as well. Many of the chap-
ters now have specific interventions identified for patients receiving home
healthcare, outpatient care, and care in long-term care settings. Pharmaco-
logic approaches that have changed so much in the last few years have been
revised and expanded throughout this new edition.

This is now our third collaboration as authors. The writing of our books has
seen us through many of life’s changes and challenges, including marriage,
birth, death of parents, and personal illness. We all have had to face these
while trying to maintain a healthy balance and get the books done on time.
We want to recognize the roles our families, friends, and colleagues have had
in encouraging us through the revision of this manuscript. We want to thank
our three contributors—Yoshi Arai and Margaret Mitchell for their excellent
chapters and Susan McGee for her work in revising some chapters. We also
want to thank Joanne DaCunha of F.A. Davis and our editor, Diane Blodgett,
for keeping us on track. We particularly want to recognize the nurses we have
worked with over the years. They have taught us so much about the demands
and rewards of our profession. That is the foundation of this book.

Linda M. Gorman

Marcia L. Raines

Donna F. Sultan
FM-Gorman 11/20/01 1:01 PM Page vii

CONTRIBUTORS

YOSHINAO ARAI, RN, MN, CS

Mental Health Counselor, RN
Harbor-UCLA Medical Center
Los Angeles County Department of Mental Health
Los Angeles, California

Clinical Nurse Specialist

Pharmacology Research Center
Harbor-UCLA Research and Education Institute
Los Angeles, California

SUSAN J. McGEE, RN, MSN

Assistant Professor of Nursing
California State University, San Bernardino
San Bernardino, California

MARGARET L. MITCHELL, RN, MN, MDIV, MA, CNS

Senior Mental Health Counselor, RN
Treatment Authorization Request Unit
Los Angeles County Department of Mental Health
Los Angeles, California

vii
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CONSULTANTS

MARCIA G. BOWER, RN, CS, MSN, CRNP

Nurse Practitioner
Chandler Hall
Newtown, Pennsylvania

PATRICIA R. DEAN, RN, MSN, CARN

Associate Professor
Florida State University
Tallahassee, Florida

LORETTA GILLIS, RN MSCN

Professor
St. Francis Xavier University
Antigonish, Nova Scotia, Canada

KIM HAYES, RN, MPA, MS

Assistant Professor, Nursing
Central Ohio Technical College
Newark, Ohio

ALICE H. SINCLAIR, RN, MSN

Supervisor, Adult Education, Health Occupations
Burlington County Institute of Technology
Medford, New Jersey

ANN G. ROSS, RN, MN

Retired, Professor
Shoreline Community College
Seattle, Washington

ix
FM-Gorman 11/20/01 1:01 PM Page xi

CONTENTS

1 INTRODUCTION TO PSYCHOSOCIAL NURSING

FOR GENERAL PATIENT CARE 1

2 PSYCHOSOCIAL RESPONSE TO ILLNESS 7

3 PSYCHOSOCIAL SKILLS 15

4 NURSES’ RESPONSES TO DIFFICULT PATIENT

BEHAVIORS 29

5 CRISIS INTERVENTION 39

6 CULTURAL CONSIDERATIONS: IMPLICATIONS

FOR PSYCHOSOCIAL NURSING CARE 43

7 PROBLEMS WITH ANXIETY 51

The Anxious Patient 51

8 PROBLEMS WITH ANGER 65

The Angry Patient 65
The Aggressive and Potentially Violent Patient 74

9 PROBLEMS WITH AFFECT AND MOOD 87

The Depressed Patient 87
The Suicidal Patient 100
The Grieving Patient 113
The Hyperactive or Manic Patient 124

10 PROBLEMS WITH CONFUSION 137

The Confused Patient 137

xi
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xii CONTENTS

11 PROBLEMS WITH PSYCHOTIC THOUGHT

PROCESSES 153
The Psychotic Patient 153

12 PROBLEMS RELATING TO OTHERS 165

The Manipulative Patient 165
The Noncompliant Patient 177
The Demanding, Dependent Patient 189

13 PROBLEMS WITH SUBSTANCE ABUSE 199

The Patient Abusing Alcohol 199
The Patient Abusing Other Substances 214

14 PROBLEMS WITH SEXUAL DYSFUNCTION 229

The Patient with Sexual Dysfunction 229

15 PROBLEMS WITH PAIN 245

The Patient in Pain 245

16 PROBLEMS WITH NUTRITION 267

The Patient with Anorexia Nervosa or Bulimia 267
The Morbidly Obese Patient 281

17 PROBLEMS WITHIN THE FAMILY 291

Family Dysfunction 291
Family Violence 301

18 PROBLEMS WITH SPIRITUAL DISTRESS 317

Margaret L. Mitchell, RN, MN, MDIV, MA, CNS
The Patient with Spiritual Distress 317

19 NURSING MANAGEMENT OF SPECIAL

POPULATIONS 331
The Patient with Sleep Disturbances 331
The Chronically Ill Patient 343
The Dying Patient 352
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CONTENTS xiii

20 PSYCHOPHARMACOLOGY: DATABASE FOR

PATIENT AND FAMILY EDUCATION ON
PSYCHIATRIC MEDICATIONS FOR ADULTS 363
Yoshinao Arai, RN, MN, CS

APPENDIX A RELAXATION TECHNIQUES 393

APPENDIX B COMPLEMENTARY AND

ALTERNATIVE APPROACHES 394

REFERENCES 395

INDEX 405
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8
Problems with Anger
THE ANGRY PATIENT

LEARNING OBJECTIVES

➢ Identify three positive functions of anger.

➢ Identify possible nurses’ reactions to an angry
patient.
➢ Differentiate among assertive, passive, and hostile
expressions of anger.
➢ Select the most appropriate interventions for
dealing with an angry patient.

GLOSSARY
Anger—A state of emotional excitement and tension induced by intense
displeasure, frustration, and/or anxiety in response to a perceived threat.
Assertiveness training—Learning behavioral techniques that allow an
individual to stand up for his or her own rights without infringing on
the rights of others.
Assertiveness—Behavior directed toward claiming one’s rights without
denying the rights of others.

65
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Frustration—Feelings generated from the inability to meet a goal.

Hostility—Feelings of anger and resentment that are destructive.
Passive-aggressive behavior—Behavior characterized by angry, hostile
feelings that are expressed indirectly, leading to impaired communica-
tion and inappropriate expression. This behavior masks anger in such a
way as to obstruct honesty in relationships. It may also be associated with
obsessive-compulsive personality, borderline personality, and depression.
Rational anger—Anger expressed in a direct, socially acceptable manner.

Anger is a universal response to frustration, rejection, and fear. It can cause

difficulty in our lives, especially when we have been taught that it is unac-
ceptable to feel angry, have learned to display our anger inappropriately, or
have developed a sense of fear that the anger can lead to abandonment. How-
ever, learning to deal with anger is an ongoing process, and when we learn
how to deal with our anger and others’ anger appropriately, we can gain a
positive feeling of control, a sense of power and energy, and increased self-
esteem. Some people fear anger because they think it could get out of control.
Generally, though, anger tends to be of short duration and low intensity for
most people. It does not necessarily lead to violence and aggression.
Anger can be viewed along a continuum. At one extreme is passive-
aggressive behavior, in which a person avoids direct, open expression of
anger but finds hidden ways to express it. At the other extreme is aggressive
expression, in which a person inflicts pain on others when he or she expresses
anger. Rational anger falls in the middle. When anger is rational, feelings are
expressed in a direct, socially acceptable manner that allows the person to
gain some control over the threat without causing harm to others.

ETIOLOGY
No single theory can explain the complex emotion of anger. Most likely, an in-
tertwining of biological, psychologic, and sociocultural factors create each in-
dividual’s unique response. Box 8–1 lists positive and negative functions of
anger.
Biologic theories of anger focus mainly on neurotransmitters, such as
dopamine, norepinephrine, and serotonin. The balance of these and other
brain chemicals seem to influence or even aggravate response to anger and
stress.
Psychologic theories look at the various dynamics and learned responses
that cause anger. Anger occurs as a result of a buildup of frustration. Paque-
tte (1998) points out that frustration and feelings of powerlessness precede
expression of anger. Children often use inappropriate anger responses, such
as temper tantrums, to deal with frustration and feelings of powerlessness.
Positive reinforcement for this behavior can cause inappropriate anger re-
sponses to continue into adulthood. When the child’s caregivers are de-
manding, hypercritical, and punitive, the child may develop coping mecha-
66
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PROBLEMS WITH ANGER 67

BOX 8–1. Positive and Negative Functions of Anger

Positive Functions Negative functions

Energizes body for self-defense Can lead to impulsive behavior
Can promote conflict resolution Can lead to hostility and rage
Can increase self-esteem and sense of control Can hurt others emotionally or physically

nisms aimed at avoiding expressing anger directly for fear of displeasing the
caregiver and risking emotional abandonment or retaliation. These coping
mechanisms often lead to a passive-aggressive anger response and resent-
ment, which eventually erupt into inappropriate or destructive behavior.
Anger can sometimes be a normal response to fear and help the person gain
control of a perceived threat, or it can be part of the adaptive process in ad-
justing to a loss. In addition, suppressed anger can contribute to depression
and low self-esteem (Townsend, 2000). Anger can also be a motivating factor
to stimulate action that in turn can raise self-esteem.
Sociocultural factors also play an important role in the way an individual
expresses anger. Social groups, including families, often display common
patterns in the degree of acceptance of expressed anger. For example, in some
families yelling and aggressive confrontation are acceptable means of deal-
ing with anger and conflict, whereas in others any overt display of anger is
not tolerated. Although both of these styles may work within individual fam-
ilies, they may not be the healthiest ways of dealing with anger.
Women are often socialized to deal with anger differently from men. They
may tend to displace or suppress angry feelings and attempt to give in and
compromise rather than deal with the conflict directly. This behavior can lead
to passive-aggressive responses or resentment that may eventually become
destructive. Such repression can also be detrimental and lead to misunder-
standing when dealing with male colleagues.

CLINICAL CONCERNS
Medical conditions, such as chronic illness or loss of body function, may
strain one’s coping abilities and lead to an uncharacteristic display of anger.
Illness often means facing feelings of powerlessness and frustration in meet-
ing one’s goals and contributes to angry responses such as irritability. Some
conditions, including some brain tumors and different forms of dementia,
may also directly contribute to inappropriate expressions of anger because of
their influence on brain function. Studies have been inconclusive on the role
of chronic anger in the development of heart disease and migraines.
Abuse of mind-altering substances may reduce inhibitions and negatively
influence the anger response.
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68 PROBLEMS WITH ANGER

LIFE SPAN ISSUES

CHILDREN
Children normally respond with anger when faced with frustration. If they are
raised in an environment where intense anger and violence are accepted, they
can develop overly aggressive anger responses including cruelty to others, an-
imal abuse, intolerance for frustration. Conversely, children who are taught
that anger is unacceptable may tend to suppress or deny angry feelings and
can develop extreme distress and guilt when faced with conflict. Children who
learn appropriate ways to relieve tensions are more able to express anger ra-
tionally. Because children are vulnerable, they may be at increased risk of in-
jury caused by inappropriate expressions of anger by caregivers.

ADOLESCENTS
Anger in adolescents is often seen as part of their developmental process of
separation from parents and asserting their individuality. Hostility can also
come from overstimulation from all they are dealing with. They may also have
fears of being unable to control their impulses, leading to anxiety about anger.

ADULTS
Adults who must deal with difficult life experiences, such as a chronic illness
or the onset of an acute illness compounding stressful life events, can become
very angry. This anger can further complicate the disease by depleting cop-
ing skills and interfering with the recommended medical treatment.

ELDERLY PEOPLE
Uncharacteristic displays of anger in elderly people may be the result of frus-
tration caused by a variety of physical, mental, and lifestyle changes such as
dementia, altered sensory function (particularly hearing loss), altered mobil-
ity, changes in sleep-rest patterns, effects of medications, depression, loss of
loved ones, and fear of dying. Inappropriate behavior may cause elderly per-
sons to be alienated, further increasing their sense of fear, frustration, and
possible confusion. Additionally, vulnerable elderly people are at risk of be-
ing victims of someone else’s anger.

POSSIBLE NURSES’ REACTIONS

• May take patient’s anger personally, causing an unhealthy emotional re-
sponse.
• May respond defensively by using an aggressive response or avoidance.
This can accelerate the anger cycle.
• May attribute the patient’s anger to a specific event, such as the quality of
care provided, and respond by feeling unappreciated and resentful.
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PROBLEMS WITH ANGER 69

• May feel uncomfortable or fearful and respond by suppressing or denying
the anger.
• May avoid confronting the patient for fear of emotional or physical retaliation.

ASSESSMENT
Behavior and Appearance
• Loud voice, change in pitch, or very soft voice, forcing other to strain to
hear (Table 8–1)
• Intense eye contact or avoidance of eye contact
• Rapid, pacing movement
• Ruminating about an issue
• Passive-aggressive behavior, possibly including sarcastic humor; chronic
complaining; socially annoying habits; pseudocompliance (agreeing to do
something but not doing it)
• Possible physical violence

Mood and Emotions

• Annoyance, discomfort, frustration, continuous state of tension
• May be quick to anger, then let it go or take time to “stew’’ before express-
ing anger
• Guilt
• Powerlessness
• Vulnerability, easily offended
• Defensive response to criticism
• Passive-aggressive emotional response, possibly including being sullen,
yet denying any concerns, or inappropriate cheerfulness for the situation

Thoughts, Beliefs, and Perceptions

• May believe that anger is normal and can be expressed without hurting
others
• May take responsibility appropriately without blaming others
• May be angry at others but still care for them

TABLE 8–1. COMPARING BEHAVIORAL RESPONSES TO ANGER

Traits Passive Assertive Aggressive

Speech content Negative: “Can I, Positive: “I can, I will” Hostile: “You never . . .
Should I” Puts self “I” messages You always . . .”
down Derogatory
Voice Whispers Firm, clear Loud
Whiny, weak
Posture Drooping Erect, relaxed Tense
Eye contact Looks down Appropriate Invasive
Gestures Fidgets Appropriate Threatening
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70 PROBLEMS WITH ANGER

• May lack ability to express true feelings

• May fear loss of love if anger is expressed directly
• May fear emotional or physical abandonment if anger is expressed
• May feel a sense of power when angry

Relationships and Interactions

• May communicate concerns clearly to avoid additional misunderstanding
• May avoid other hostile or angry persons
• May be catered to by others who fear patient’s anger

Physical Responses
• Fight-or-flight response during confrontations, possibly including rapid
pulse, increased blood pressure, rapid breathing, muscle tension, sweat-
ing, or intense feelings of wanting to attack or run
• Episodes of headaches, depression, sleep alterations, pain, or gastroin-
testinal symptoms associated with repressed anger

COLLABORATIVE MANAGEMENT
Pharmacologic
Antianxiety medications, including benzodiazepines, are sometimes used for
short-term relief of feelings of tension and anger. However, they should not be
used as a substitute for acknowledging and dealing with anger, and they should
not interfere with pharmacologic actions of medications being taken for the un-
derlying medical condition. In addition, antidepressants may be effective in
controlling impulsive and aggressive behavior associated with mood swings.
Beta blockers have also been used occasionally to control aggressive behaviors.
Common herbal products used for tension include St. John’s wort, kava
kava, and valerian.

NURSING MANAGEMENT
ANXIETY EVIDENCED BY TENSION, DISTRESS, UNCERTAINTY, REST-
LESSNESS, OR DISPLEASURE RELATED TO THREAT TO SELF-CONCEPT,
FRUSTRATION, OR UNCONSCIOUS CONFLICT.

Patient Outcomes
• Verbalizes concerns and frustrations directly at an appropriate time
• Demonstrates reduced tension including lowered voice and more appro-
priate anger response
• Demonstrates problem-solving skills when faced with frustration
• Demonstrates behaviors to calm self when faced with frustration
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PROBLEMS WITH ANGER 71

Interventions

• Use therapeutic communication techniques including open-ended ques-

tions, appropriate eye contact, and supportive gestures to encourage pa-
tient to vent feelings and concerns. Avoid providing solutions before the
patient has a chance to relieve tension.
• Listen with concern without being patronizing or condescending. Phrases
such as “Tell me what happened next” or “That really sounds frustrating”
allow the patient to feel accepted and understood. Avoid phrases that es-
calate feelings of powerlessness, such as “Calm down” or “It can’t be that
bad.”
• If needed, direct the patient to a more private setting to express his or her
feelings. Having others view the demonstration of anger can make it more
difficult to back down and contribute to escalation of hostility or aggres-
sion.
• When the tension of the situation is reduced, focus on identifying the
source of anger and validating the problem. Explore options on how to
deal with the problem more constructively. Ask the patient which meth-
ods he or she has used successfully in the past when dealing with frustra-
tion. Teach problem-solving skills. Assist the patient to identify and use
more effective coping mechanisms.
• Teach tension-reducing techniques, such as deep breathing, counting to 10,
walking away, and talking to self about remaining in control.
• Encourage the patient to express angry feelings toward the appropriate
person. Role playing before the confrontation may help the patient choose
effective strategies.
• Recognize that an angry outburst may result from an accumulation of mul-
tiple stressors and cause the patient to overreact.
• If the patient is justifiably angry because of something you have done or
not done, accept appropriate responsibility. Work with the patient or col-
leagues to resolve the problem. Accepting and validating the patient’s feel-
ings sends the message that you value his or her viewpoint.
• Encourage children to vent frustration by redirecting their activity, such as
hitting a pillow or engaging in exercise.

INEFFECTIVE INDIVIDUAL COPING EVIDENCED BY INAPPROPRIATE

EXPRESSION OF ANGER, DISTRESS, DESTRUCTIVE BEHAVIOR TO
SELF OR OTHERS, AND RELATED TO THREAT TO SELF-ESTEEM OR
UNCONSCIOUS CONFLICT.

Patient Outcomes

• Able to identify personal strength that may help to reduce stress

• Accepts personal limits in dealing with inappropriate demands
• Demonstrates effective skills for dealing with frustration
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72 PROBLEMS WITH ANGER

Interventions
• Identify ways to increase the person’s self-esteem as part of expressing
anger by treating him or her respectfully and acknowledging his or her
skills or attributes. For example, when dealing with an angry daughter’s
confrontation about her parent’s care, state, “Your father is lucky to have
you as his advocate.” Avoid a defensive response or ignoring complaints.
• Focus on the patient’s strengths to deal with frustration. Help him or her
identify which coping skills have been successful in the past.
• Teach the patient that anger is a normal response to loss. Some individuals
are unable to accept this anger as normal and experience unneeded guilt.
• Encourage the patient to state the cause of the problem clearly to avoid er-
roneous assumptions.
• If the patient rejects or finds fault with all of your suggestions, place the re-
sponsibility for choosing the appropriate response on the patient. You
might say, “We’ve discussed many options. Now it is up to you to consider
which one is best for you.”
• Set clear limits on the patient’s expressions of anger toward the staff.
Refuse to listen to extensive complaining if the patient is not willing to par-
ticipate in determining an acceptable solution.
• Be assertive when explaining which types of behavior are not appropriate.
• Be consistent with the demands the patient can set on the staff.
• Be a role model for expressing negative emotions in a positive manner. Use
“I messages,” such as “I feel angry” rather than accusing the other person,
which can lead to a defensive response. Speak firmly without yelling and
avoid threatening gestures when confronting issues.

ALTERNATE NURSING DIAGNOSES

Impaired Social Interaction
Noncompliance
Risk for Violence
Self-Concept Disturbance

WHEN TO CALL FOR HELP

Increased aggressiveness; violent behavior, including damaging prop-
erty; increasing use of abusive language, threats made to patients or
staff
Onset of paranoid thinking or psychotic behavior
Onset of extreme obsessive-compulsive behavior
Increased staff conflict over management of patient behavior
Increased staff anxiety over caring for patient
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PROBLEMS WITH ANGER 73

PATIENT AND FAMILY EDUCATION

• Teach assertiveness skills by role-modeling appropriate responses and
helping the patient practice these skills.
• Review with the patient frequently encountered frustrations, and explain
that giving up control of the outcome may be the most effective strategy
for dealing with them.
• Review potential negative health effects of inappropriate anger expression.
• If the patient is using antianxiety medications, review the need to monitor
their use and avoid using them in place of trying to resolve the cause of
anger.

CHARTING TIPS
• Use objective, nonjudgmental terms to describe behavior.
• Document patient’s response to frustration.
• Document the limits set on care plan or treatment plan for consistency.
• Document use of medications (including herbal products) and patient’s re-
sponse to them.

COMMUNITY-BASED CARE
• Communicate plan of care to all involved in discharge planning.
• Inform any appropriate agencies of patient behaviors to avoid miscom-
munication.
• Refer patient to counseling services or assertiveness training, if needed.
• Encourage patient’s active participation in treatment plan.
08-Gorman 11/20/01 1:08 PM Page 74

THE AGGRESSIVE AND POTENTIALLY

VIOLENT PATIENT

LEARNING OBJECTIVES

➢ Identify factors that precipitate aggressive

behavior.
➢ Describe effective techniques for verbal
deescalation of aggressive behavior.
➢ List possible nursing staff reactions to violent
behavior in patients.
➢ List interventions a nurse could use in working with
a violent patient.

GLOSSARY
Aggression—Any verbal or nonverbal, actual or attempted, forceful
abuse of the self or another person or object.
Assaultive behavior—An intentional act that is designed to make an-
other person fearful and produces harm.
Hostility—Anger that is destructive in nature and purpose as opposed
to rational anger that is appropriate to the situation and is not destruc-
tive in intent.
Intimidation—The use of threats to frighten and control.
Physical restraint—Any physical method of restricting an individual’s
freedom of movement, activity, or normal access to his or her body.
Rage—Engulfing emotional experience of extreme anger.
Violent behavior—Exertion of extreme force or destructive acts with in-
tent to hurt another and that can cause injury.

The presence of violence in our society has unfortunately become increasingly

common. This increased violence is also reflected in the healthcare setting. High
rates of violent, assaultive behavior have been reported in hospitals, emergency
departments, nursing homes and home health care. U. S. Labor Department sta-

74
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PROBLEMS WITH ANGER 75

tistics report that 64 percent of nonfatal workplace assaults take place in hospi-
tals and nursing homes. However, psychiatric nurses are at highest risk. Poster
(1996) found that over 75 percent of psychiatric nurses had been assaulted at
least once in their careers. Historically, nurses working with psychiatric patients
have been taught to be alert to and manage violent, assaultive behavior; how-
ever, now all healthcare workers need to be alert to this problem. Healthcare fa-
cilities must institute security measures and policies to ensure the safety of staff
and patients and to reduce the fear of impending violence among staff and vis-
itors. Consistently being confronted with aggressive and potentially violent pa-
tients, families, and visitors can cause excessive fear, stress, job dissatisfaction,
lost work time, poor morale, and possible injury. The Occupational Health and
Safety Administration (OSHA) has developed voluntary guidelines for em-
ployers to address this problem. They created “Universal Precautions for Vio-
lence,” which acknowledges that violence should be expected but can be
avoided or mitigated by proper training, policies, and security measures.
Past history of violence is the greatest predictor of this behavior. In addition,
a history of psychiatric illness, particularly schizophrenia, paranoia, border-
line personality disorder, other personality disorders, post-traumatic stress
disorder, and dementia is frequently associated with predicting an aggressive
outburst. Other major risk factors include drug and alcohol use. Studies show
that young men are by far the most frequent perpetrators of violent acts.
The causes of the increased violence in our society and, consequently, in
health care are varied and complex. Some of these causes include:

• Attitudinal changes in society with increased acceptance of violent response

to authority figures
• Increased prevalence of handguns among patients, families, and visitors
• Increased use of mind-altering drugs and alcohol
• Court decisions that give psychiatric patients the right to refuse treatment
and medication
• Healthcare staff members inadequately prepared to respond to aggression
or who deny the risk of violence and fail to report it
• Increasing frustrations in health care settings, including inadequate staffing
and long waits
• Healthcare workers in isolated environments (e.g., examining rooms, in
patient’s home) with no backup, communication devices, or alarms
• Impersonal care, which may stress already frustrated patients
• Legal and ethical concerns about using chemical and physical restraints
• Media coverage of violence, which triggers additional crimes

Using restraints to manage potentially violent patients can create ethical

dilemmas for the nurse concerning patient autonomy, human dignity, and in-
formed consent. In 1993, the Joint Commission on Accreditation of Health Care
Organizations ( JCAHO) created standards for physical restraints, requiring
each agency to provide clear policies and education on appropriate restraint
use. They have continued to refine these because of ongoing problems ( JCAHO,
2000). The aim is to reduce the incidence of injuries that can result from restraint
use, such as loss of mobility, skin breakdown, and, possibly, death from stran-
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76 PROBLEMS WITH ANGER

gulation. In 1999, Medicare and Medicaid developed new federal standards for
the use of restraints. Restraints can be applied only with a physician’s order for
each occurrence. Continuous assessment of the patient while he or she is being
restrained must be done, and alternatives to restraints must be tried.

ETIOLOGY
Aggressive, violent behavior has many causes. Most studies of the causes of
aggression have been done on subjects with mental illness or prison popula-
tions, which may skew the results.
Biologic theories include genetics, which links chromosomal abnormalities
to aggressive behavior, hormone imbalances, and neurotransmitter irregular-
ities, specifically the abnormal secretions of dopamine and serotonin.
Psychologic theories on aggression are related to a person’s view of the world
as a source of anxiety. Individuals prone to violence often have low self-
esteem and need to maintain control to enhance their own feelings of power
and self-worth. Fear and anxiety can distort an individual’s perception of the
stimulus. The presence of alcohol or other drugs can further distort these and
reduce inhibitions. Aggressive behavior temporarily reduces the anxiety and
creates a temporary sense of power. In addition, individuals with poor im-
pulse control or a personality disorder may use violence to intimidate others.
Aggressive individuals may have limited ability to tolerate frustration and de-
mand to have their needs met immediately. Individuals who have experi-
enced emotional deprivation in childhood may be particularly vulnerable and
respond with violent outbursts when they sense an attack on their self-esteem.
Social learning theory views aggression as a learned behavior. Individuals
with a tendency toward aggressive, violent behavior may be more likely to
respond to stressors such as illness, school or work pressures, or relationship
problems with anger and hostility because they have learned that such be-
havior temporarily reduces their anxiety.
Sociocultural theories look at an aggressive individual’s poor interpersonal
skills. Exposure to aggression and violence as part of family life may also be a
significantly influential factor. Children who are treated with violence may
view violence as a normal way to deal with others. The cycle of family violence
continues when children learn to use violence as their only coping mechanism
instead of more socially acceptable ones. Poverty, deprivation, and hopeless-
ness can also increase the risk of violent behavior.

RELATED CLINICAL CONCERNS

A wide variety of organic disorders may be associated with aggressive and
violent behavior. These include:
INTRACRANIAL DISORDERS
Brain tumors
Head injury
Seizure disorders
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PROBLEMS WITH ANGER 77

Cerebrovascular accident
Dementia
SYSTEMIC DISORDERS
Endocrine disorders such as thyroid storm or Cushing’s syndrome
Electrolyte imbalance
Oxygen deficiency
Septicemia
Hepatic encephalopathy
EXPOSURE TO SUBSTANCES
Alcohol use or withdrawal
Use of mind-altering substances such as phencyclidine and ampheta-
mines
Withdrawal from barbiturates and sedatives
Use of aromatic hydrocarbons (glue, paint)
Use of medications such as steroids, central nervous system stimulants,
and anti-Parkinsonian agents
Exposure to toxic chemicals, pesticides, lead

LIFE SPAN ISSUES

CHILDREN
Constant exposure to violence in childhood is a major factor contributing to the
cycle of child abuse and family violence. Children who learn to use violent be-
havior to cope with frustrations and problems are likely to carry these behav-
iors into adulthood and may need to learn effective coping skills. Early signs of
problems may include cruelty to animals and other children as well as diffi-
culty controlling responses to frustration. The alarming presence of violence in
schools and neighborhoods and in the media has increased the number of chil-
dren who are exposed to seeing aggressive behavior and weapons used to re-
solve frustration in what may appear to them to be socially acceptable, normal
behavior. Autism, mental retardation, learning disabilities, and attention
deficit disorders may also cause aggressive and violent behavior in children.

ADOLESCENTS
Adolescents may act out aggressive feelings by participating in self-destructive
behavior such as drug or alcohol use, smoking, or crime. Using mind-altering
substances increases the risk of violent behavior. Homicide is the leading cause
of death in the 15–24 age group (Dowd, 1998).

ADULTS
Aggressive behavior in adults often reflects lifelong learned patterns. For in-
stance, persons who abuse their spouses have often witnessed abuse in their
parents’ relationship or been abused themselves as children.
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78 PROBLEMS WITH ANGER

ELDERLY PEOPLE
Like anger, violent behavior can be a lifelong pattern or be caused by physi-
cal illness or adverse reactions to medications. Aggressive behavior may also
be a self-protective response related to confusion, fear, or sensory loss (par-
ticularly hearing loss). Most frequently, aggressive behavior in elderly per-
sons is associated with Alzheimer’s disease, senile dementia, cerebrovascu-
lar accidents, metabolic disorders, and hypoxia.

POSSIBLE NURSES’ REACTIONS

• May fear being hurt by the violent or aggressive patient or one who uses
intimidation with the threat of violence. This fear can cause the nurse to
use poor judgment or totally deny feeling fearful. Other common fear re-
sponses include avoiding the patient or bending the rules in an attempt to
appease the patient. All of these responses can affect continuity of patient
care.
• May feel abused and unappreciated, leading to defensive responses such
as attempting to punish the patient. Defensive responses and treating pa-
tient with less respect can escalate anger.
• May feel guilty for not being able to control the behavior or feel uncom-
fortable for participating in applying restraints.
• May feel offended or frustrated because the patient does not respond to
care positively.
• A nurse who has been assaulted in the past may experience self-blame and
question his or her competence, depression, anxiety, and hyperalertness to
any situation that could lead to aggressiveness.

ASSESSMENT
Behavior and Appearance
• Pacing, restlessness
• Tense facial expression and body language
• Unpredictable behavior
• Loud voice, shouting, use of obscenities, argumentative
• Overreacting to stimuli such as noise
• Exhibiting poor impulse control evidenced by acting quickly before con-
sidering consequences of actions
• Grasping potential weapons and attempting to use them

Mood and Emotions

• Anger, resentment, rage, hostility
• Anxiety; fear of loss of control leading to panic
• Inappropriate affect for situation, labile emotions
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PROBLEMS WITH ANGER 79

Thoughts, Beliefs, and Perceptions

• Low self-esteem
• Low frustration tolerance
• Thoughts or plans to harm someone
• Inability to trust others to follow through without strong intimidation and
suspiciousness
• Hallucinations, paranoid delusions
• Views others as out to hurt him or her
• Sense of being out of control

Relationships and Interactions

• Difficulty with close relationships; lack of trust, which causes person to
fear closeness
• Others fearful of and avoid aggressive person, believing that they might be
hurt or manipulated
• Family and friends have learned to meet person’s demands to avoid ag-
gressive response or exhibiting passive-aggressive behaviors in response
to the person’s demands

Physical Responses
• Increased muscle tension
• Increased heart rate and blood pressure
• Altered level of consciousness, confusion, lethargy
• Possible abnormal laboratory values including blood sugar, blood alcohol,
drug screening
• Increased use of medications

Pertinent History
• History of violent behavior, particularly assault
• Psychiatric diagnosis
• Substance and/or alcohol abuse
• Physical, emotional, or sexual abuse in childhood

COLLABORATIVE MANAGEMENT
Pharmacologic
It is important to use appropriate medications in adequate doses as an alter-
native or adjunct to physical restraints to manage aggressive behavior.
Pharmacologic management of acute aggressive or violent behavior may
require rapid neuroleptization (also known as rapid tranquilization), which in-
volves regular, frequent administration of antipsychotic medications such as
haloperidol (Haldol). Parenteral administration may be required if oral route
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80 PROBLEMS WITH ANGER

is not feasible. If the patient is in physical restraints, parenteral administra-

tion reduces the risk of aspiration. For example, haloperidol, 5 mg, may be
administered every 30 to 60 minutes until symptoms are under control.
Dosage should be reduced in elderly people. When using this drug, monitor
the patient closely for hypotension and signs of extrapyramidal symptoms
including akathisias and dystonia (see Chapter 20).
Antianxiety medications and sedatives may also be useful. Anticonvul-
sants, such as carbamazepine (Tegretol), have been used with some success.
Lithium and beta blockers, such as propranolol, are other alternatives. Anti-
depressants have also been used to treat impulsive, aggressive behavior.
When using these drugs, evaluate how they may interfere with the medica-
tions ordered to treat the patient’s underlying medical condition.
Convincing an aggressive, agitated patient to accept medication can be dif-
ficult and may lead the nurse to face an ethical dilemma of giving medication
against a patient’s will. Be aware of hospital or agency policies and state laws
regarding patient rights (Box 8–2).
Herbal products, such as valerian, may be used to calm the person.

NURSING MANAGEMENT
RISK FOR VIOLENCE, DIRECTED TO OTHERS EVIDENCED BY OVERT
HOSTILITY AND/OR AGGRESSION TO OTHERS, THREATENING OTHERS,
POSSESSION OF POTENTIAL WEAPON, ASSAULTING OTHERS RELATED
TO IMPAIRED JUDGMENT, FEELINGS OF POWERLESSNESS, IMPULSIVE
BEHAVIOR, INABILITY TO EVALUATE REALITY SECONDARY TO NEURO-
LOGIC PROBLEMS, PSYCHOTIC THOUGHTS, AND/OR DRUG/ALCOHOL USE.

BOX 8–2. Encouraging an Uncooperative Patient to Take Medication

• Have the nurse who has the best relationship with patient offer the medication.
Avoid power struggles and confrontations, which would most likely escalate the
situation.
• Have the medication in hand so that it can be given quickly when the patient
gives consent. The patient may change his or her mind suddenly.
• Be prepared for the patient to spit out the medication. This is especially com-
mon in elderly, aggressive patients.
• Use liquid oral medication if available. It is absorbed more quickly and is less
likely to be “cheeked.” If medication needs to be given by injection, work
quickly. Have adequate staff available in case violence erupts.
• Review with the patient the benefits of medication and that it will help him or
her gain control of his or her feelings.
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PROBLEMS WITH ANGER 81

Patient Outcomes
• Demonstrates increased self-control while in nurse’s care
• Does not harm others or self while in nurse’s care
• Demonstrates alternative coping mechanisms to reduce tension while in
nurse’s care
• Behavior does not escalate while in nurse’s care

Interventions
• Help patient to verbalize angry feelings by reflecting and by clarifying your
understanding of these feelings. Communicate your interest by appropriate
eye contact, restating what patient has said, and asking questions. Help pa-
tient identify source of anger. Recognize that response to illness may make
the person feel helpless with the need to strike out to gain a sense of control.
• Early recognition of problem behavior is essential so that staff members
can develop a plan.
• If needed, allow patient to release tension physically on inanimate objects
such as pillows or in prescribed exercise, as appropriate.
• Do not take patient’s behavior personally. For example, if a patient calls
you derogatory names, refrain from reacting emotionally. Rather, remind
yourself that you represent an authority figure to the patient and he or she
is reacting to you as such. Remember that patient may use derogatory re-
marks as a way to bolster his or her own self-esteem and seem to zero in
on your sensitive, vulnerable points, such as weight or speech patterns.
Avoid responding with sarcasm or ridicule.
• Do not ignore aggressive behavior in the hope that it will go away. It needs
to be addressed. Minimization of behavior and ineffective limit setting are
the most frequent factors contributing to escalation to violence.
• Set clear, consistent limits in a timely manner on what will and will not be
tolerated. Clarify any specific consequences of patient behavior. For ex-
ample, “If you attempt to hurt anyone, we will be compelled to control
your behavior, which may mean using restraints”(Box 8–3).
• Identify one or two staff members who are comfortable with the patient to
handle most of the care if possible to help provide consistent interventions.
Evaluate whether a male or female staff member has a more calming influ-
ence. Sometimes a male’s presence is too threatening and powerful. Other
times it is reassuring to the patient that a male staff member is available. A
male patient may be less likely to hurt a woman and may see her as nurtur-
ing and supportive. Conversely, male patients may view the female staff as
less able to provide control or have other conflicted feelings toward women.
• Free patient’s environment of extra stimulation, such as noise or an agi-
tated roommate. Extra stimulation may reduce impulse control. Remove
objects around patients that could be used as potential weapons such as
portable IV poles or food trays and utensils. Consider providing plastic
food dishes and utensils. Avoid startling patient. Call patient by name be-
fore walking into room. Avoid sudden movements that the patient may in-
terpret as threatening.
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82 PROBLEMS WITH ANGER

BOX 8–3. Setting Limits

1. Explain exactly which behavior is inappropriate. Don’t assume the individual

knows which behavior is inappropriate.
2. Explain why the behavior is inappropriate. Don’t assume the individual knows
why the behavior is inappropriate.
3. Give the individual reasonable choices or consequences. Present them as
choices, and always present the positive first.
4. Allow time—if you don’t allow time to comply, it may be perceived as an ul-
timatum.
5. Enforce consequences—limits don’t work unless you follow through with the
consequences.

Source: Reprinted from the Art of Setting Limits Participant Manual, p. 8, with permission of the
National Crisis Prevention Institute, Inc., © 1991.

• Remain calm and communicate that you are in control and can handle the
situation. Use a moderate, firm voice and calming hand gestures. Avoid
touching patient. Table 8–2 lists a summary of staff interventions.
• Place yourself between door and patient. Always have a quick exit avail-
able. Never turn your back on this type of patient. Keep door of room open.

TABLE 8–2. SUMMARY OF STAFF INTERVENTIONS

Patient Staff
Anxiety Verbal intervention:
• Assess.
• Use verbal calming techniques.
• Attempt to calm patient.
• Do not invade patient’s personal space; avoid antagonizing.
Threatening Set Limits:
• Continue verbal calming techniques.
• Set clear and definite limits.
• Be directive and matter of fact.
• Be prepared to enforce limits.
Acting out aggression Physical management:
• Recognize mounting tension.
• Have a plan.
• Designate team leader.
• Use only after other measures fail.
Tension reduction Emotional support:
• Allow patient to express feelings.
• Listen nonjudgmentally.
• Show concern for patient, not anger.
• Discuss events with colleagues.
• Avoid blaming.
Source: Adapted from Haven and Piscitello, 1989, and Lewis, 1993.
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PROBLEMS WITH ANGER 83

Let other staff members know you are going in patient’s room. Protect
other patients who may get in the way of the violent individual.
• Never force an agitated patient to have a test or treatment. Power struggles
will escalate aggression. Rather, prioritize care that must be given and fo-
cus only on that. Explain all procedures and ask patient’s permission be-
fore beginning. Give patient choices as often as possible.
• If the patient is psychotic, he or she may be hearing voices. If so, ask what
the voices are telling him or her to do. This gives you more information on
what to expect. Hallucinations that command the patient to initiate ag-
gression can be an extremely powerful force for the patient to overcome.
• A nurse who has been assaulted in the past and is now faced with a po-
tentially violent patient may bring fears from this past experience, which
could inhibit his or her response. Sharing these fears with colleagues may
provide much needed support. Use agency resources for support includ-
ing employee assistance or critical incident debriefing to help colleagues.
• If a patient makes threats to harm specific people, the nurse needs to notify
his or her supervisor and follow protocol for notifying potential victims.
• A visitor who becomes aggressive or violent needs to be reported to the
agency security staff immediately and removed from the patient care area.
• Ensure that measures and policies are in place to prevent workplace vio-
lence. See Box 8–4.
• In the patient’s home setting, be aware of exits in case a problem develops.
Never stay alone in a home with a patient or family who is threatening vi-
olence, drinking, or displaying firearms. Consider making home visits
with a colleague when there is a known risk of violence. Leave the home
immediately if there is any sign of out of control behavior. Have access to
a cellular phone in case of emergency.
RISK FOR INJURY EVIDENCED BY FALLS, PAIN, TRAUMA, SKIN BREAK-
DOWN RELATED TO RESTRAINING PATIENT TO CONTROL VIOLENT BE-
HAVIOR.

BOX 8–4. Preventing Workplace Violence

• Be particularly vigilant during change of shifts and on night shift. Most events
occur between 8:30 p.m. and 10:30 a.m.
• Minimize stress factors such as long waits, crowded, confined spaces, and in-
flexible policies for patients where possible.
• Avoid wearing jewelry or neckties that can be grabbed or tugged.
• Immediately report all assaults to your supervisor and security.
• Be aware that many agency security staffs have minimal training.
• Receive education on local gangs and gang violence.
• Participate in agency safety committees to ensure that adequate security mea-
sures are in place.
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84 PROBLEMS WITH ANGER

Patient Outcomes
• Remains free of injury and complications during restraint application
• Demonstrates control of behavior once restraints are removed

Interventions
• The decision to use restraints should be made only after other efforts to re-
duce tension have been tried and proven ineffective. A physician’s order
must be obtained each time restraints are to be used. Standing orders are
not acceptable.
• Once decision is made to restrain patient, act quickly and decisively. De-
termine what appropriate type of restraint is to be applied before ap-
proaching patient. Restraints include cloth chest and limb restraints or
leather (hard) locked restraints. (Note: When using hard restraints, make
sure you have the key, and double-check that they are locked after applying
them to patient.) Have equipment ready before approaching patient.
• Never attempt to restrain a patient by yourself. Have adequate staff mem-
bers available (usually three to five persons) and a plan of action before at-
tempting to physically control a patient. Recruit reliable help from all pos-
sible sources, such as security. Assess their experience in managing a
violent patient and review the plan. Decide in advance who will grab
which arm or leg if patient must be restrained. The presence of a number
of staff members (show of force) alone may subdue a patient. Identify a
leader before taking any action.
• Designate one person to talk with the patient and another to direct the
other staff. Only one staff member should talk with patient, preferably
someone who knows him or her. It is important to communicate in a firm
manner, speaking slowly. Lack of leadership can cause confusing and con-
tradictory messages and result in someone being hurt or the patient es-
caping. Remove other patients from the area.
• Maintain a firm base of support for balance if you are suddenly pushed.
Remove name badge, eyeglasses, jewelry, and so on to avoid injury.
• If patient is resisting, he or she may need to be distracted. Each staff mem-
ber should grab one of the patient’s limbs when given the command by the
coordinating person and take patient down to the floor or bed quickly. At-
tempt to cradle patient’s head to prevent injury.
• Once restraints are applied to bed frame, take the time to talk with the pa-
tient in a calm, concerned manner to try to humanize situation. Call patient
by his or her name.
• Make sure patient has no potential weapons within reach. Patient needs to
be searched for sharp objects, matches, and so on.
• Administer medications as ordered.
• Be aware of agency policy regarding application of restraints. Require-
ments for monitoring patients while in restraints, reasons for restraints,
doctor’s orders, and the length of time each order remains valid should be
clearly spelled out in agency policies. If you are not sure about using re-
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PROBLEMS WITH ANGER 85

straints on someone, discuss with your supervisor to weigh your obliga-
tions to protect the patient versus going against the patient’s wishes.
• Monitor patient closely and document findings according to agency policy
including vital signs, circulation extremities, and intake/output.
• Remove restraints and observe patient closely when the situation is under
control. Consider removing restraints from one limb at a time so that pa-
tient has time to adjust. For the high-risk patient, keep one arm and one leg
in restraints at all times until it is clear that patient can be released. Inform
other staff members that patient has been released. Establish clear criteria
for reapplying restraints with patient and staff. Prepare family for patient’s
condition, as appropriate.
• Once the patient has regained control, discuss with him or her why that in-
tervention was used, and allow opportunity to express feelings. This in-
creases his or her sense of control and decreases dehumanization.
• If patient has a gun or other weapon, never attempt to disarm him or her.
Contact security and/or law enforcement agency as soon as possible. Fo-
cus on getting assistance and protecting patients and staff. Patients and
staff should remain in a safe area until help arrives.
• Consider taking a specialized class on use of defensive techniques such as
management of assaultive behavior. Proper training is essential to prevent
injury to patients and staff. Staff members can practice with each other to
demonstrate how they would handle a violent patient.
• Identify jobs at higher risk of exposure to violence and ensure that em-
ployees in these jobs have adequate training.

ALTERNATE NURSING DIAGNOSIS

Altered Thought Processes
Ineffective Individual Coping
Noncompliance
Anxiety
Self-Esteem Disturbance

WHEN TO CALL FOR HELP

Escalation of behavior from aggressive to violent

Patient in possession of a weapon
Inadequate staff members available to control behavior
Increased staff anxiety over caring for the patient
Staff members at risk for violence without adequate training/security
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86 PROBLEMS WITH ANGER

PATIENT AND FAMILY EDUCATION

• Review early warning signs of escalation of aggressive behavior with pa-
tient and his or her family.
• Instruct patient on role of alcohol and drugs in contributing to aggressive
behavior.
• Instruct on use of prescribed medications to control tension. Instruct on
when to ask for PRN medications.
• If patient is in restraints, review with him or her criteria for removal and
reinstatement.

CHARTING TIPS
• Document all actions taken to prevent violent behavior.
• Document application of restraints including type, length of time in re-
straints, reasons for application, patient response, release of limbs, and
care given while in restraints. (Document per agency policy.) Document vi-
tal sign monitoring.
• Document need for and response to medication given.
• Document any threats patient makes.
• Document all interventions and responses to them.

COMMUNITY-BASED CARE
• Provide information to patient’s family and/or caregivers about emer-
gency psychiatric services, if needed. Discuss potential for violence with
family to share possible strategies from nursing care plan.
• Provide information on shelters and/or domestic violence services, if ap-
propriate.
• If patient is being transferred to another facility, share concerns about pa-
tient’s behavior and interventions and share any history of violent behavior.
• Provide information to family and caregivers on what to do if behavior is
out of control. Encourage them to call for help immediately.
• Provide information and referrals on drug treatment if appropriate.